1. Contributors: Michael Power, PhD, Emily Kahn, PhD, Jennifer Williams, MSN, MPH, Denise Jamieson, MD, MPH, Kitty MacFarlane, CNM, MPH, Jay Schulkin, PhD, Yujia Zhang, PhD, and William Callaghan, MD, MPH Attitudes and Practices of Obstetrician-Gynecologists Regarding Influenza Vaccination in Pregnancy National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health Dmitry Kissin, MD, MPH Division of Reproductive Health, CDC

2. Disclaimer The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy

3. Background  Pregnant women are at high risk for influenza-related complications, including severe disease  Neonates are at high risk for morbidity and mortality from respiratory infections, but active immunization for influenza is not successful in newborns or infants <6 months of age  Use of influenza vaccine in pregnancy can benefit both the woman and her infant  Inactivated influenza vaccine is recommended for all women who will be pregnant during influenza season  Vaccination can occur in any trimester of pregnancy

4. Study Objectives  Assess knowledge, attitudes and practices of U.S. obstetrician- gynecologists regarding influenza vaccination during pregnancy  Assess barriers and facilitators to influenza vaccination during pregnancy among U.S. obstetrician-gynecologists

5. Study Methods   Study population and sampling:   Random sample of U.S. obstetrician-gynecologists   ACOG fellows or junior fellows in ACOG database   Only ob-gyns currently involved in obstetric patient care   Survey:   Self-administered mail survey (cover letter and pre-paid envelope)   Questions about basic demographics, experience with ILI in their practice, attitudes and practices re: influenza vaccinations   No incentives were offered   Timeline:   Initial mailing in February 2010, right after the peak of H1N1 pandemic   Follow-up survey to non-respondents at 4- to 5-week intervals

6. 3,116 Surveys mailed 3,096 Ob-gyns received survey 1,310 Ob-gyns completed survey 873 Ob-gyns provided obstetric care 20 Surveys returned as undeliverable 1,784 Did not respond 2 Declined participation 34,985 Ob-gyns in ACOG database 437 Did not provide obstetric care 42.3% (1,310/3,096) Response rate Enrollment

7. Characteristics of Participating Ob-Gyns Characteristics% or Mean (Range) Sex Female Male 51.1 48.9 Average age, years49 (30-85) Average years in practice17 (0.5-52) Practice type Group ob-gyn Solo Multispecialty group University faculty & practice Other 48.1 16.4 12.4 11.2 11.9 Considers primary care an important part of practice Very important Important Not important 45.8 49.4 3.8 Average est. % patients eligible for Medicaid 33.4 Average est. % patients by race/ethnicity Non-Hispanic white Non-Hispanic African American Hispanic Asian or Pacific Islander Native American Multiracial Other 54.9 15.2 17.8 5.3 1.3 2.6 1.0

8. Observing Serious Conditions Attributed to ILI Proportion of ob-gyns who reported observing at least one of the serious conditions in their practices that they attributed to influenza-like illness (ILI)

9. Attitudes and Practices re: Influenza Vaccination Characteristics Seasonal influenza vaccine 2009 H1N1 influenza vaccine Offering influenza vaccination to pregnant patients Routinely offered Not offered, but referred Neither offered or referred 77.6 21.1 1.1 85.6 13.3 1.2 Offering influenza vaccination to specific groups of pregnant patients Healthy low-risk High-risk with chronic condition Pre-pregnancy obesity 75.3 71.0 83.4 82.4 77.5 Recommending influenza vaccination to pregnant patients Do not recommend Recommend during any trimester Recommend during 2 nd or 3 rd trim. 0.5 88.9 10.6 0.5 89.9 9.6 Requirements for med. staff to receive influenza vaccination Required Strongly encouraged Not required 33.8 63.2 2.9 33.9 62.4 3.3 Received influenza vaccination themselves Yes No 91.7 8.3 89.8 10.2

10. Year(s)Population Screen, recommend and offer vaccine Reference 1999ob/gyns, n=31348% screen; 39% offer vaccineGonik et al, 2000 2000ob/gyns, n=11367% offer vaccineSilverman, 2001 2001ob/gyns, n=56244% offer vaccineSchrag et al, 2003 2001-02 ob/gyns, n=20; fam. physicians, n=66 68% (ob/gyns) and 90% (fam. physicians) store vaccine Wallis et al, 2004 2004ob/gyns, n=3773% offer vaccineWu et al, 2006 2004ob/gyns, n=413 52% (1 st trim) and 95% (2-3 rd trim) recommend Bettes et al, 2005 2007ob/gyns, n=39452.5% offer vaccinePower et al, 2009 2006-09ob HCW, n=267 65% recommend, 52% and 40% offer vaccine Broughton et al, 2009 2009-10ob/gyns, n=858 77.6% offer seasonal and 85.6% offer H1N1 vaccine Kissin et al, in press Do obstetricians and other providers offer influenza vaccine to pregnant women?

11. Reasons for Not Offering Influenza Vaccine Seasonal influenza vaccine 2009 H1N1 influenza vaccine Not adequately reimbursed by insurance34.9%31.7% No adequate storage and handling facilities for vaccines 28.0%35.8% Vaccine offered by closely affiliated clinic21.7%28.5% Managed care contract does not cover the cost of vaccines and vaccine administration 20.1%17.1% Belief that vaccines should be administered by another provider, such as an internist or family practitioner 15.3%14.6%

12. Sources of Guidance re: Influenza Vaccination for Pregnant Women Source of Guidance Percentage of ob-gyns using the source ACOG60.8% CDC54.1% Public Health Department18.8% Own practice11.9% Scientific literature5.6% Media3.9%

13. Predictors of Offering Influenza Vaccine Characteristics Routinely offered vaccine (%) Adjusted Prevalence Ratio All85.6- Practice type Group ob-gyn Solo Multispecialty group University faculty & practice Other 86.6 66.9 98.1 91.8 88.0 Ref 0.8 1.1 1.0 Considers primary care an important part of practice Very important Important Not important 88.4 84.6 73.2 1.2 1.1 Ref Observed serious conditions attributed to ILI Yes (at least one) No 91.1 83.0 1.1 Ref Received influenza vaccination themselves Yes No 87.2 69.6 1.2 Ref

14. Summary   Most ob-gyns routinely offered influenza vaccinations to their patients   A considerable proportion of ob-gyns did not offer vaccination or did not recommend vaccination in the first trimester of pregnancy   Barriers to recommending and administering influenza vaccination among ob-gyns included financial and logistical concerns (inadequate reimbursement, absence of storage and handling facilities)   Solo practice providers were less likely to offer influenza vaccination, but more likely to consider primary care a very important part of their practice

15. Recommendations  Utilize available approaches to increase vaccination during pregnancy:  Engage in educational and promotion activities for obstetric providers  Collaborate with professional organizations on provider education  Promote standing orders for influenza vaccinations  Address financial (insurance coverage and reimbursement), administrative and logistical concerns (especially among solo practice providers)  Encourage providers to be vaccinated themselves  Design, implement and evaluate interventions to improve vaccination coverage among pregnant women

16. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Thank You! Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion

17. Additional Slides

18. Seasonal influenza vaccination coverage for pregnant women, NHIS, 1997-2009 n=372n=335n=332n=337n=294n=319n=315n=156n=180n=126n=123n=113n=177

19. Seasonal and H1N1 influenza vaccination coverage for pregnant women, 2009-10 BRFSS NHFSHarvard Poll n=163n=161n=260n=255n=514 Healthy People 2020 Goal

20. Barriers for obstetricians and other providers to vaccinate pregnant women  FINANCIAL: Inadequate reimbursement, cost of purchase and storage 1-8  LOGISTICAL: Not part of usual practice, lack of vaccine availability, lack of time, lack of comfort with administration, lack of staffing 1,3,5-8  LEGAL: Liability concerns 3,4,6-8 1 Gonik et al, 2000. 2 Wallis et al, 2004. 3 Naleway et al, 2006. 4 Panda et al, 2010. 5 Power et al, 2009. 6 Schrag et al, 2003. 7 Wu et al, 2006. 8 Dolan et al, unpublished.

21. Barriers for obstetricians and other providers to vaccinate pregnant women - continued  KNOWLEDGE: Uncertainty about recommendations, lack of knowledge about increased morbidity of pregnant women from influenza, lack of knowledge about conferring passive immunity to infant, lack of data on effectiveness 1-5  ATTITUDES/PRACTICES: patient demand low or patient unwillingness, not being vaccinated themselves 2-6  SAFETY: Concerns about safety for pregnant women and fetus, concern about preservatives, concerns about vaccination during the first trimester 2-7 1 Gonik et al, 2000. 2 Naleway et al, 2006. 3 Power et al, 2009. 4 Schrag et al 2003. 5 Wu et al, 2006. 6 Panda et al, 2010. 7 Dolan et al, unpublished.

22. Provider/system- based and access- enhancing interventions to increase vaccination during pregnancy  Provider reminder systems: chart prompts, printing vac. record  Provider assessment and feedback: monitoring and reporting vaccination rates  Standing orders: vaccination by healthcare personnel without direct physician involvement, encouraged by ACIP  Provider education: active education, promotion activities, vaccination training, communication with ob providers through letters and calls from ACOG, AMA leadership*  Enhancing access to vaccinations: providing vaccine directly to ob providers (2009-10), vaccination clinics for pregnant women and their partners* Sources: CDC, MMWR 2000. Naleway et al, 2006. Ndiaye et al, 2005. Mouzoon et al, 2010. Ogburn et al, 2007. Panda et al, 2010. Wallis et al, 2006. Mills, Maine Dept of Health, personal communication, 2010. Koelemay, Seattle King County Health Dept, personal communication, 2010. *Interventions not formally evaluated